Epidemiology
· 3rd
leading cause of accidental death amongst children
· Mortality
– higher for children and the elderly
· 2005:
>120,000 children <15 years of age received care in ED for burns / COMBUSTIO
· Children
<5 years old: 65% scald injuries
· 5-20
years old: 27% scald injuries
· Non-accidental
burns: estimated as high as 20% of burn admissions
· Inhalational
injury increases mortality significantly
Pathophysiology:
1. Local injury:
heat denatures and coagulates protein => irreversible tissue destruction
o
Surrounding this => zone of decreased
tissue perfusion (salvageable tissue)
o
Young children have thinner skin =>
deeper burns
o
Increased capillary leak around burn
2. Systemic response:
release of vasoactive mediators from tissue: cytokines, prostaglandins, O2 radicals
o
>15% burn in young children, >20%
burn in older children: systemic response to mediators
o
Systemic capillary leak lasts 18-24
hours => burn shock/SIRS
o
Immunosppuression
o
Local destruction of RBC’s
o
Myocardial depression
o
Hypermetabolic response: catecholamine
release, glucagon, cortisol elevation
3. Advocacy:
with140-150 degree water (normal for home water heater): 3rd degree burn in approximately
2 seconds
o
Reset
water heaters to 120 degrees
Classification
of Burns:
· Depth
of burns : based on intensity and
duration of thermal exposure
· Superficial burns
(1st degree) : erythematous,
painful
o
Only involve outer layer of epidermis
(fluid loss not an issue)
o
Heal without scarring in 4-5 days
· Partial thickness burns
(2nd degree)
o
Superficial
partial thickness: red and painful with blister formation
Partial
destruction of dermis
Weeping/moist
appearance
Healing
in 7-10 days with minimal scarring
o
Deep
partial thickness: greater than 50% of dermis lost
White,
pale, less painful (nerve fibers destroyed)
2-3
weeks to heal, severe scarring can occur, contractures
May
requires skin grafting
·
Full thickness
burns
(3rd degree): white, waxy, leathery
o
No bleeding, painless
o
High risk for infection and fluid loss
· Fourth degree burn : destruction of
underlying structures – tendons, nerves, muscle, bone, deep fascia
Estimation of Burn Area
(do not include superficial burns) :
· Adolescents/adults:
rule of 9’s
o Head/Arm: 9% each
o Leg, anterior trunk, posterior
trunk: 18%
o Neck and groin: 1% each
· Children:
surface of child’s palm = 0.5% TBSA
o Modified Lund and Brower chart
(see image)
Initial Assessment/Evaluation
· ABC’s
· Inhalational
injury
o
Upper airway edema
o
Bronchospasm
o
Small airway occlusion from debris, endobronchial
sloughing
o
Circumferential burn on chest – limits
chest wall compliance
o
Susepect: history of closed space
exposure, facial burns, singed nasal hairs, carbonaceous debris in the mouth
o
Secure the airway if suspected (cuffed
tube)
· Insert
2 large bore IV’s for fluid management (okay to insert IV’s through burn)
· Remove
burnt clothing/jewelry
· Cover
burn with clean sheet/blanket: reduces pain, decreases fluid/heat loss
· Eye
examination
o
Evaluate for corneal burns with
fluorescein – before edema of eyelids develops
· Flame
burns – consider CO poisoning
o
Dx with carboxyhemoglobin level
o
Administer 100% O2, consider hyperbaric
O2 for level >30%
o
100% O2 decreases half life of CO from
250 minutes at room air to 40-50 minutes
· Note
any circumferential burns on the body
· Labs:
CBC, lytes, UA (myoglobin), carboxyhemoglobin
Criteria
for admission to burn unit (American Burn Association)
1. Partial-thickness
burns of greater than 10% of the total body surface area
2. Burns
that involve the face, hands, feet, genitalia, perineum, or major joints
3. Third-degree
burns in any age group
4. Electrical
burns, including lightning injury , chemical burns
5. Inhalation
injury
6. Burn
injury in patients with preexisting medical disorders that could complicate
management
7. Any
patients with burns and concomitant trauma (such as fractures) in which the
burn injury poses the greatest risk of morbidity or mortality
8. Burned
children in hospitals without qualified personnel or equipment for the care of
children
9. Burn
injury in patients who will require special social, emotional, or
rehabilitative intervention
Fluid
Management
· Aggressive
management required for patients with >15% of TBSA burned
o
Parkland: 4ml/kg/%TBSA
Children<5 y/o: add maintenance
fluids
Give half in the 1st 8 hours
Give the other half in the next 16 hours
o
Fluid: LR, add dextrose for children
<20kg
· Add
colloid after 24 hours to help restore oncotic pressure
· Monitor:
goal uop: 1-2ml/kg/hr, acidosis
· Not
improving with initial resuscitation?
o
Consider
continued volume loss, myocardial depression, neurogenic shock
Nutrition :
· Higher
caloric needs due to hypermetabolic state
· Begin enteral nutrition as soon as
possible
o
Demonstrated better outcomes with
enteral feeding vs TPN
· Can
feed duodenum if concerned for risk of aspiration
· GI
prophylaxis – Curling’s Ulcers: Zantac or Prilsoec
Other
Considerations
1. Infection
o
Decreased rates of wound infection, but
patients live longer => Increased rates of central catheter infection and
ventilator associated PNA
o
Global decrease in immune function:
neutropenia, t-cell dysfunction, increased gut permeability, many blood
transfusions
o
Wound sepsis: staph/pseudomonas most
common
No ppx abx
Rates have improved significantly with
prompt wound closure
o
ENT: ear poorly vascularized
Sinusitis/OM: indwelling tubes
o
Optho: corneal ulcer infection
o
Pulmonary: inhalational injury =>
pneumonia v. tracheobronchitis (35%)
Ventilator associated PNA
o
Central venous catheter infections/UTI
o
Intraabdominal infection
o
Musculoskeletal: compartment syndrome,
suppurative costal chondritis, abscess
o
Viral (immunosuppression): HSV, CMV,
varicella reactivation
o
Fungal infection due to prlonged abx
(candida, aspergllus)
o
Prevention: catheter care, early wound
closure, culture/abx with fever/hypotension (be judicious!), topical abx
o
Tetanus
o
Infection control programs
2. Abdominal
compartment syndrome
o
After large fluid resuscitation with
capillary leak
o
Pressure > 25-30cm H2O
o
Decreased renal perfusion,
cardiovascular output, pulmonary compliance
3. Pain
control + anxiolysis
Wound
Care
· Initial
care – never put ice!
o
Cover with sterile sheet
o
Cool with water 10-20 minutes after burn
· Topical
abx: decrease both risk of infection, fluid loss from burn
o
Silver sulfadiazine: painless, poor
eschar penetration, broad antibacterial spectrum, no metabolic side effects.
o
Mafenide: Penetrates tissue well, broad abx
spectrum, painful on application. Application to >20% tbsa may lead to
metabolic acidosis
o
Bacitracin: often used for burns of
face, painless, no pigment bleaching (can be seen with silver sulfadiazine)
o
Aqueous silver nitrate 0.5%: painless
application, poor eschar formation, leeches electrolytes
· Elevate
burned extremity to minimize edema
· Decompressive
escharotomy essential with compartment syndrome, circumferential scar
Sources:
1. Reed,
JL and WJ Pomerantz. Emergency management of pediatric burns. Pediatric
Emergency Care. 21 (2): Feb, 2005: 118-129.
2. Sheridan,
RL. Sepsis in pediatric burn patients. Pediatric Critical Care. 6(3), 2005:
S112-S119.
3. Andel,
H et al. Nutrition and anabolic agents in burned patients. Burns. 29. 2003:
592-595.
4. Uptodate.com:
Joffe, MD. Emergency care of moderate and severe thermal burns in children
5. Uptodate.com:
Mandel, J and CA Hales. Smoke inhalation.
6. Bressack,
M. Inpatient management of pediatric burns. Santa Clara Valley Medical Center.
7. American Burn Association website
No comments:
Post a Comment